Irwin: Sure! I’m a clinical social worker, and I also came out as a gay man in the 1970s when I was in college, so years later when I started my private practice, I thought it was important to be out as a therapist in my community. When I first started my practice in 1984, about two-thirds of my clients identified as gay, lesbian, or bisexual. I saw a smattering of trans people, but not many. Starting in about 2004, though, I began to get a lot of referrals of transgender youth from True Colors, a wonderful LGBTQ youth service organization that is also based here in Connecticut. All of a sudden I had a practice that had more and more transgender clients, so I took it upon myself to get educated on the subject. I went to some presentations at the True Colors conference, I read whatever I could, and learned a lot from my clients themselves.

In working with transgender teens and their parents, I began to see that most of these parents had the same basic set of needs and concerns that needed to be addressed. In 2011 I wrote Helping Your Transgender Teen, which is a book for parents that covers basic information about transgender identities and addresses typical fears and concerns that many parents have. I also lead one- and two-day trainings for mental health clinicians who are not experienced in working with transgender youth but want to be. Then, a little over a year ago, I was approached by Jessica Kingsley Publishers to write Counseling Transgender and Non-Binary Youth, which is my new book for mental health clinicians and is based on these trainings that I’ve been doing.

Grace: What kinds of things do your clients come to you needing to talk about, and where are they typically at in their transition?

Irwin: Well, in terms of teens and young adults, anyone under 18 is usually coming to me with their parents’ involvement. Generally these were kids who had come out to their parents as trans and then either the parents found me or, in some cases, the kids found me themselves. There’s a lot of variability in where each of my clients were at in their transition prior to stepping foot in my office. There were kids who came to see me after they had effectively made a social transition at school, meaning that their friends and maybe even some teachers were addressing them by their chosen name and pronouns. And then there were other kids who had maybe told a friend or peer, but hadn’t told their parents yet. Still others were not certain about identifying as transgender but had some concerns around gender that they needed to discuss. Every story is really different in terms of the child’s own sense of who they are, how they came to understand that, and who they choose to share it with.

Grace: What about their parents? Where are they usually at in their own process when you first meet them?

Irwin: The parents were usually coming in with positions ranging from those whose first response was, “How can I help?” to others who were really floored by this news and thought that their kid had gotten some crazy idea, maybe from their peers, and was just trying to stand out from the crowd. I’d say the most typical parent was somebody who really loved and cared about their kid and wasn’t afraid that they were making a misstep, but wanted to understand as much as they could about it. Some parents may have been secretly hoping that we would discover that their child was not transgender because, in their mind, that is such a challenge in life to have. Of course, there were also parents who were really angry and hostile about it, and were looking to me to hopefully “talk their kid out of it.” I did lose some of those parents’ participation once they understood that I was neutral-to-positive about this.

Grace: Are there any mental health issues that transgender and nonbinary youth are particularly susceptible to?

Irwin: I would say the most common mental health issues are depression and anxiety. I think that a big chunk of that is due to having something you know about yourself that you expect—usually correctly so—that other people will have difficulty with, and then they have to grow up (as all LGBTQ kids still do) surrounded by these negative messages in the culture or in their family. Kids from religious backgrounds, especially, are oftentimes surrounded by very negative views on LGBTQ identities. So I think that naturally and understandably leads to depression and/or anxiety. I’ve seen kids who had really shut down and were self-harming or having thoughts about suicide, or who had made suicide attempts already. And then I’ve seen other kids who were very anxious—biting their nails, unable to sleep, those kinds of things. Generally, once the transgender identity, or at least the question of it, was expressed by the youth and endorsed at least half-decently by the family, or even just if they felt like they had an ally in me and were on the road to somewhere better, then there was a reduction or elimination of those symptoms. Some people really got all better as far as the mental health picture goes, and some people continued to struggle with some of those issues to some degree. Of course, there are some transgender people who have more significant depression or anxiety, just like there are many cisgender people who do.

Grace: Right. Something that I want to underline in that is the role of discrimination and not feeling supported in your environment, and the impact that those things have on mental health. I wish more people understood that trans people—or LGBTQ people in general—are not inherently mentally ill; they’re not inherently depressed, they’re not inherently anxious. Rather, it’s this combination of environmental factors that makes life really difficult and that leads to certain coping mechanisms or certain behaviors. I think that’s really important to acknowledge.

Irwin: Right, exactly. That’s actually one of the reasons why I make the point in my book about why the gender dysphoria diagnosis, which is currently in the mental health book of diagnoses called the DSM, really belongs on the medical side of things. They’re working on something along the lines of “Gender Incongruence” on the medical side as a way of medically indicating a person for whom gender affirming treatments are appropriate, whether that’s hormones or surgery. That’s really where that diagnosis needs to be, rather than alongside other listed mental illness. It’s there currently to help people get access to medical treatments, and is something therapists use to recommend such treatments. For example, I have to include a gender dysphoria diagnosis in the letters that I write to surgeons on behalf of my clients, but I am also committed to saying, “This is not a mental illness. It is something that requires medical treatment.” One example that I like to use is if a cisgender boy develops breast tissue and wants it removed, we call it Gynecomastia and consider it something that is medically treatable. But if a transgender boy needs his breasts removed, there is much more question about whether or not it’s necessary. I try to make those points to normalize the process and recognize that gender is a big deal in all of our lives. Even if we’re not questioning our gender, we’re still constrained by these forces and it is unlikely that any person is going to fit the bill of a typical boy or typical girl for their whole lives.

Grace: Yes, absolutely. What kinds of treatments or therapies have you found to be particularly effective for your clients?

Irwin: For teenagers and young adults, family therapy can be extremely beneficial. We have a lot of research to show that LGBTQ youth with rejecting families tend to have more troublesome mental health outcomes, and kids with supporting families or even less rejecting families do a whole lot better. The most important thing for me is to engage with the parents to try and help ease their worries, which in turn should help them behave in ways that are more supportive towards their kid. A lot of parents are scared about a lot of things and end up behaving in ways that are hurtful to their kids—but their goal isn’t to hurt their kids, their goal is to keep their kids from making what they think is a big mistake. Even when the client is 18 or older, I still encourage them to include their parents in as many ways as they can. Of course there is the one exception of someone who grew up in such a hateful environment that they were waiting until they were 18 to get out of the house to do this, but otherwise I think everybody can use some improvement in their family situation. The piece of therapy that is most effective is helping the young person explain in detail to their parents what their life experience has been in relation to gender. To do this, I first meet with the youth one-on-one to get a sense of what their immediate concerns are, and to do a Gender Identity Evaluation, which is a discussion to help us understand the person’s sense of their gender and how that has developed over the course of their life so far. I then meet with the parents separately to find out what their biggest fears and concerns are, and to help them address those fears and concerns through gaining more information, meeting with other parents who have already been through this with their own child, and so on. Finally I get everyone together and basically interview the young person in front of their parents and guide them in sharing their experiences and feelings around gender. I have found that when parents hear a detailed narrative from their kid, and they hear, “I didn’t just dream this up yesterday, I told you yesterday, but I’ve been thinking about this for a lot longer,” it can help ease some of those worries. That’s the biggest turning point in the family therapy usually, and that in turn makes the biggest difference for the outcome for the child. Having the parents on board really facilitates everything else that these young people need to do, whether it’s advocating for their kid at school or helping them get access to certain medical treatments.

Grace: Exactly. I want to talk a little bit about access to mental health professionals and counselors that are affirming of various gender identities, because not everyone does have access to a therapist as knowledgeable as yourself! What is your advice to people who live in an area that doesn’t have a counselor trained in these issues?

Irwin: Well, I do think people have to find a counselor who is at least LGBT friendly or it’s just not going to be helpful. Everyone who does this work probably started their own journey of understanding trans issues by having a client who was trans or questioning their gender identity and then the counselor was open-minded enough to start learning more about it by reading or going to conferences. In some ways, I think going to the closest therapist who is somehow known to be LGBT friendly is a pretty good start, even if they don’t specialize in gender identity or trans issues. Before stepping foot in their office, parents can call them and screen for that as well. Hopefully there are more and more trans-friendly therapists throughout the country, and I do include in my book a couple of lists where people can find names of therapists in different locations. Unfortunately for some people, it might mean driving an hour or two for an appointment, as inconvenient as that is. In that case, it might mean not having weekly appointments—but again these individuals do not have mental illnesses, so they don’t necessarily need weekly appointments. And there are probably a significant number of therapists who would conduct the therapy by phone after meeting you in person as well, if you live far away.

There are also other things that parents and kids can do that can be helpful. In a lot of ways, going to a few conferences can really accomplish a fair amount of what therapy itself is trying to accomplish, and that is just providing clarity and endorsement of the child’s gender identity and giving them a place to speak. For young people especially, there’s a tremendous amount of support online, so kids can get support by watching YouTube videos or by participating in TrevorSpace, which is a monitored social networking space for LGBT youth by The Trevor Project. And then, of course, Everyone Is Gay and My Kid Is Gay have so much information and support for kids and parents alike. For a lot of trans kids, they just need someone to be their lifeline—someone to say to them, “It’s ok to be trans, lots of people are, and it’s a perfectly natural way to be.”

Grace: Something we hear a lot on My Kid Is Gay from parents is, “My kid came out as trans, and I’m just worried that their life is going to be harder, and I don’t want them to needlessly go down this more difficult path when it doesn’t have to be this way.” What’s your response to that?

Irwin: Yes, that is a very common concern, worrying about a bleak future with no friends, no luck with relationships, just total rejection. My own experience coming out as gay in the 1970s was very much the same—the expectation for gay men in the 1970s was that you would be having anonymous sex, you would be lucky if you could keep your job, and you would wind up being the pathetic old guy sitting at the bar. But those of us who were gay knew we were different than that, and these trans kids know that too. There are a couple things that are really valuable in helping parents with this. One is going to parent support groups or to conferences like Philadelphia Trans Health Conference, Gender Spectrum ConferenceGender Odyssey, or Gender Conference East in order to meet other parents and hear how their kids are doing. Parents that are in these various support groups are in different stages of the process, so if you’re new to this, hearing from other people that their kids who came out a year or two ago are really doing quite well can be really helpful. Meeting transgender adults can also be helpful: seeing that they are happy and that, despite whatever hardships they may have faced, they still don’t regret their decision to transition. The other thing that I recommend for parents is reading memoirs written by transgender people, to see that trans people have creative and happy lives with lots of friends and relationships and definitely challenges that are different than the challenges that cisgender people face, but they feel good about being authentically themselves.

Of course I don’t mean to make light of the real risks that trans people face, or make light of people who have lost their jobs or faced violence because they are trans. But still, the outcomes for so many people are positive, especially when we think about the alternative, which is telling trans kids, “Don’t be yourself, pretend to be cisgender, and live a life that feels miserable to you.” The option of not transitioning is not a safe and happy one by any means. In fact, it’s a very unhappy one that has a lot of risk in terms of self-harm and depression. Being your authentic self is joyful and important and giving that up to avoid other risks is ultimately a very hard way to live.